Clin Oral Impl Res 2000: 11: 34–38 Copyright C Munksgaard 2000

Printed in Denmark ¡ All rights reserved

ISSN 0905-7161

An assessment of the accuracy of ridge-

mapping in planning implant therapy for the
anterior maxilla
Allen F, Smith DG. An assessment of the accuracy of ridge-mapping in Finbarr Allen,
planning implant therapy for the anterior maxilla. David G. Smith
Clin Oral Impl Res 2000: 11: 34–38. C Munksgaard 2000.
Department of Restorative Dentistry, The
The use of ridge-mapping to assess bone levels available for implant place- Dental School, University of Newcastle
ment in the anterior maxilla avoids some of the problems associated upon Tyne, UK
with CT scanning. The aim of this study was to assess the accuracy of
ridge-mapping callipers in determining bony ridge widths in the anterior
maxilla prior to dental implant surgery. A modified surgical stent was
designed to locate the beaks of ridge-mapping callipers at the same points
on the jaw before and after mucoperiosteal flap reflection. Eleven subjects
were included in the study. Measurements (nΩ100) were made at 25 im-
plant sites, 50 ‘‘pre-operative’’ and 50 ‘‘intra-operative’’ at 3 mm and 6 Key words: implants – ridge-mapping –
measurement
mm distances from the crest of the ridge. There were statistically significant
(P∞0.0001) differences between pre- and intra-operative measurements.
F. Allen, Department of Restorative
Based on pre-operative measurements, clinical judgements were made as
Dentistry, The Dental School,
to whether supplementary procedures such as guided bone regeneration University of Newcastle, Framlington
would be required. Unanticipated supplementary procedures were required Place, Newcastle upon Tyne NE2 4BW,
at 10 fixture sites. The findings indicate that ridge-mapping alone is insuf- UK
ficient to accurately predict bone available for implantation in the an- e-mail: p.f.allen/ncl.ac.uk
terior maxilla. It is suggested that ridge-mapping may provide reliable
information about bone levels when the labial aspect of the anterior Accepted for publication 30 December
ridge is not markedly concave. 1998

The use of implants to retain crowns and bridges
is an important addition to treatment options for
restoring anterior tooth spaces. Success rates re-
ported with this form of treatment have been com-
parable with complete implant retained prostheses
(Avivi-Arber & Zarb 1996; Henry et al. 1996).
A critical factor in achieving a satisfactory out-
come is careful planning. Ideally, implants should
be surrounded by at least 1 mm of bone. In the
anterior maxilla, accurate assessment of bone di-
mensions is complicated by irregular resorption
patterns and thickness of the overlying mucosa.
Commonly used radiographic techniques such as
intra-oral periapical and panoramic views are
hampered by image distortion and inability to im-
age in a bucco-lingual cross section. Conventional
(Eckerdal & Kvint 1986) and computerised
(Schwarz et al. 1989) tomographic imaging have a
significant advantage in that cross-sectional im-
aging is possible. Lam and co-workers (1995) have
shown that significant differences in bone height
measurements occurred in their comparison of
panoramic radiography and 2-D orthoradially for-
matted CT images. While commending the use of
CT imaging for assessing bucco–lingual bone di-
mensions, they did, however, indicate problems in-
herent with the use of this technique. These in-
cluded the length of time to produce an image (20–
25 min), the cumulative radiation dose to the head
and neck area, and, the possibility of a distorted
image with metallic tooth restorations and/or pa-
tient movement. A further consideration with CT
imaging is financial cost.
The measuring of ridge width can also be accom-
plished using ridge-mapping callipers. This tech-
nique involves penetrating the buccal and lingual
mucosa down to bone (following the administration
of local anaesthetic) with callipers designed for this

34
 Assessment of accuracy of ridge-mapping in implant therapy

buccal and palatal aspects of the acrylic at 3 mm

Fig. 1. Ridge-mapping callipers.
purpose (Fig. 1). A series of measurements of the
proposed implant site can be made prior to reflec-
tion of a mucoperiosteal flap. The technique has
been advocated by Wilson (1989) and Traxler et al.
(1992), who suggest that it is a convenient and re-
liable method for assessing suitability of potential
implant sites. However, there is no information cur-
rently available as to how accurate this technique is.
The aim of this study was to determine the accuracy
of measurements of bone dimension recorded by
ridge-mapping callipers. It was anticipated that the
study would yield information as to the most appro-
priate use of this technique.
and 6 mm from the crest (Fig. 2). Prior to surgery,
and following administration of local anaesthetic,
the measuring stent was located in the patient’s
mouth. The callipers were located using the holes,
and measurements made at the 3 mm and 6 mm
points, as shown in Fig. 3. Where the callipers were
clearly gripping only soft tissue (which occurred
occasionally at the 3 mm point), the stent was re-
moved and two further holes cut apically to the 6
mm point. The stent was then relocated and a
further measurement was recorded. A clinical esti-
mation was then made on whether a supplemen-
tary surgical procedure would be required, namely
ridge expansion and/or guided bone regeneration.
Following reflection of the mucoperiosteal flap,
the measuring stent was relocated, and the meas-
urements were repeated as before.
All data were recorded on a proforma by the
operator’s assistant, and entered onto a computer
database. Pre-operative and intra-operative meas-
urements were compared using Wilcoxon’s signed
rank test. Using a one way analysis of variance, a
within subjects coefficient of variation was calcu-

Method
Eleven patients for whom implant procedures (ad
modem Branemark) were planned to restore tooth
spaces in the anterior maxilla were involved in the
study. Twenty-five sites in the inter-canine region
were identified as suitable for implant placement
following clinical and radiographic examination.
For each patient, panoramic and long cone peri- Fig. 2. Modified surgical stent designed to locate ridge-mapping
apical radiographs were used. A diagnostic wax- callipers.
up was used in each case to help determine the
orientation of the implant required to achieve the
desired cosmetic outcome.
To assess the accuracy of the ridge-mapping cal-
lipers, it was planned to measure ridge widths at 2
sites per proposed fixture both before (‘‘pre-operat-
ive’’) and after (‘‘intra-operative’’) mucoperiosteal
flap reflection. These measurements would then be
compared. An acrylic stent was designed to locate
the ridge-mapping callipers in the same location
for the pre-operative and intra-operative measure-
ments. Using a cast made from an impression of
the patient’s maxillary teeth, a heat cured acrylic
stent was constructed. Using the crest of the al-
veolus as a reference point, holes large enough to
accommodate the calliper tips were cut through the Fig. 3. Pre-operative measurement of ridge width.

35
Allen & Smith
lated to quantify error in the method. This coef-
ficient represented the standard deviation divided
by the sample mean, multiplied by 100 to give a
percentage.
Results
A total of 100 measurements were made at 25 im-
plant placement sites in 11 patients. Reasons for
tooth loss were: following trauma (nΩ8), congeni-
tal absence (nΩ2), and caries (nΩ1).
There were statistically significant differences be-
tween preoperative and intraoperative measure-
ments at both the 3 mm and 6 mm sites
(PÆ0.0001). Preoperative measurements tended to
overestimate the amount of bone available to place
the implant. At 2 sites, the preoperative measure-
ment underestimated the bone width. The within
subjects coefficient of variation was 63%, which in-
dicates the wide margins of error associated with
the ridge-mapping method.
Using the preoperative bone measurements as
an estimate of ridge width, a clinical decision was
made as to whether a supplementary surgical pro-
cedure was likely to be required. The decision was
accurate in 15 implant sites. The prediction was
inaccurate at the remaining 10 sites for the follow-
ing reasons:
1) an unanticipated, supplementary procedure was
required following reflection of the flap, as
threads on the fixture were not completely cov-
ered (nΩ5);
2) an anticipated procedure was not actually re-
quired (nΩ1);
3) the supplementary procedure was more in-
volved than anticipated, e.g. the need for ridge
dilation was anticipated, but guided bone re-
generation was actually required (nΩ4).
Discussion
The method for locating the ridge-mapping calli-
pers previously described proved to be satisfactory
for the purpose of data collection. In two cases,
some difficulty was encountered in locating the
palatal aspect of the stent following mucoperi-
osteal flap reflection. These difficulties were re-
solved with minor modification to the stent.
The results of the study indicate that the ability
of the ridge-mapping callipers to determine ridge
width is variable. The tendency to overestimate the
bone width was especially notable. This is prob-
ably due to the callipers not completely penetrat-
ing the overlying mucosa down to bone. Such a
problem can arise if the overlying mucosa is par-
ticularly thick, as is often the case following
trauma for example. The occurrence of under-
36
estimation of bone width may be explained by
squeezing the beaks of the callipers too tightly. As
the bone in this area is markedly cancellous, ex-
cessive pressure on the callipers may have caused
the beaks to penetrate through the outer cortical
layer of bone. Should the clinical decision on the
amount of bone available for implantation rely
completely on this mode of assessment, then as-
sessment may frequently be inaccurate. Conse-
quently, unanticipated supplementary surgical pro-
cedures may be required, such as guided bone re-
generation (GBR). This, in turn, may incon-
venience the patient, particularly if further surgery
is required.
A further important part of the planning pro-
cess is to determine the nature of the surgical pro-
cedures required to place the implant. As part of
the study protocol, operators were asked to make
a judgement as to whether they felt supplementary
surgical procedures would be required. This judge-
ment was based on the preoperative ridge callipers
measurement and panoramic radiographs. In ap-
proximately 40% of cases, the surgery to place im-
plants involved unanticipated GBR or ridge di-
lation to completely cover fixtures. As before, it
seems that the use of ridge-mapping callipers in
isolation will not enable accurate determination of
bone levels in the anterior maxilla. This is not sur-
prising, as the pattern of bone resorption/remodel-
ling in this region is irregular. Following flap re-
flection and placement of the implant, fenestration
of the labial plate occurred in a number of cases. It
was not possible to determine this likelihood using
ridge-mapping callipers.
As suggested previously, there are difficulties in
universally accepting a single assessment method
when planning implants in the anterior maxilla.
The ridge-mapping method has the advantage of
being simple to use, and avoids exposure to radi-
ation for the patient. In the majority of cases in
the study, surgery proceeded uneventfully, with the
bony ridge widths predicted prior to surgery prov-
ing to be reasonably accurate at surgery. It is sug-
gested that in situations where marked concavity
of the labial aspect of the bony ridge is evident,
one should consider using CT scanning to supple-
ment clinical assessment. This would enable the cli-
nician to decide if ridge dilatation would be suf-
ficient to completely cover proposed fixtures, or if
onlay grafting was essential. In cases where the
pattern of resorption appears more regular, and
where mucosa is of a more even thickness, ridge-
mapping with panoramic and intra-oral radi-
ography may prove adequate. However, the possi-
bility of fenestration may not be predicted using
these assessment methods, and the patient should
be advised of the possible need for GBR.
 Assessment of accuracy of ridge-mapping in implant therapy
Résumé
L’utilisation de la localisation du rebord osseux pour détermi-
ner les niveaux osseux disponibles pour le placement d’implants
dans le maxillaire antérieur évite quelques-uns des problèmes
associés avec le scanning CT. Le but de cette étude a été de
déterminer la valeur des repérages pour l’évaluation du rebord
osseux en déterminant les largeurs de rebords osseux dans la
région maxillaire antérieure avant le placement des implants.
Une gouttière chirurgicale modifiée a été fabriquée pour locali-
ser les becs des repérages pour l’évaluation du rebord osseux
aux mêmes points de la mâchoire avant et après l’élévation du
lambeau mucopériosté. Onze sujets ont été inclus dans cette
étude. Cent mesures ont été faites au niveau de vingt-cinq sites
implantaires: cinquante avant l’opération et cinquante durant
l’opération à des distances de 3 à 6 mm du rebord osseux. Il y
avait des différences statistiquement significatives (P∞0.0001)
entre les mesures faites avant et pendant l’opération. Basés sur
les mesures effectuées avant l’opération, les jugements cliniques
étaient établis pour savoir si des processus supplémentaires
étaient requis comme par exemple une régénération osseuse gui-
dée. Des processus supplémentaires non-anticipés ont été requis
au niveau de dix sites. Ces découvertes indiquent que l’évalua-
tion du rebord osseux seul est insuffisante pour prédire de ma-
nière sûre le volume osseux disponible pour le placement d’im-
plants au niveau maxillaire antérieur. L’évaluation du rebord
osseux apporterait donc une information sûre concernant les
niveaux osseux lorsque l’aspect vestibulaire du rebord antérieur
n’est pas vraiment concave.
este estudio fue la de valorar la precisión de los calibradores de
trazado de mapas de cresta en la determinación de la anchura
de la cresta ósea en el maxilar anterior previo a la cirugı́a de
implantes dentales. Se diseñó un acceso quirúrgico modificado
para localizar las protuberancias de calibre de trazado de ma-
pas en los mismos puntos de la mandı́bula antes y después del
levantamiento de colgajos mucoperiósticos. Se incluyó a once
sujetos en este estudio. Se hicieron mediciones (nΩ100) en 25
lugares de implantes, 50 ‘‘preoperatorias’’ y 50 ‘‘intraoperato-
rias’’ a 3 mm y 6 mm de distancia de la cresta ósea. Hubo
diferencias estadı́sticamente significativas (P∞0.0001) entre las
mediciones pre- e intraoperatorias. Basados en las mediciones
preoperatorias, se realizaron juicios clı́nicos, tales como, si se
requerı́an procedimientos complementarios, como regeneración
ósea guiada. Se requirieron procedimientos suplementarios no-
anticipados en 10 fijaciones. Los hallazgos indican que el traza-
do de mapas de la cresta por si solo no es suficiente para prede-
cir con precisión el hueso disponible para implantación en el
maxilar anterior. Se sugiere que el trazado de mapas puede
proporcionar una información fiable sobre los niveles óseos
cuando el aspecto labial de la cresta anterior no es marcada-
mente cóncavo.

Zusammenfassung
Wenn vor der Eingliederung von Implantaten das Knochenan-
gebot durch Aufzeichnung des Kammprofils ermittelt wird, so
können gewisse Probleme, die mit den CT-Schnittaufnahmen
auftreten können, vermieden werden. Es war das Ziel dieser
Studie, die Genauigkeit der Aufzeichnung des Kieferkammpro-
fils mittels Tastzirkeln in der anterioren Maxilla vor der Einglie-
derung von dentalen Implantaten zu untersuchen. Es wurde
eine modifizierte Orientierungsschiene entwickelt, welche es er-
möglichte, die Spitzen der Tastzirkel zur Aufzeichnung des Kie-
ferprofils sowohl vor als auch nach Präparation eines Mukope-
riostlappens genau auf dem Kieferknochen lokalisieren zu kön-
nen. Elf Patienten nahmen an der Untersuchung teil. Die
Messungen (nΩ100) wurden an 25 Implantatstellen durchge-
führt. Fünfzig der Messungen wurden ‘‘präoperativ’’ und 50
Messungen wurden ‘‘intraoperativ’’ in einem Abstand von 3
und 6 mm von der Spitze des Kieferkammes aus durchgeführt.
Es bestanden statistisch signifikante Unterschiede (P∞0.0001)
zwischen den prä- und intraoperativen Messungen. Basierend
auf den präoperativen Messungen wurde klinisch beurteilt, ob
vor der Implantation zusätzliche Massnahmen wie etwa eine
gesteuerte Knochenregeneration nötig sein werden. Unvermute-
te zusätzliche Massnahmen wurden bei 10 Stellen, an denen
Implantate geplant waren, nötig. Diese Ergebnisse zeigen, dass
die Aufzeichnung der Kieferkämme allein für die zuverlässige
Voraussage, ob genügend Knochen für eine Implantation in der
anterioren Maxilla vorhanden ist, ungenügend genau ist. Es
wird vorgeschlagen, dass die Aufzeichnung des Kieferprofils
nur zuverlässige Ergebnisse über das Knochenangebot liefert,
wenn der labiale Aspekt des anterioren Kieferkammes keine
ausgeprägten Konkavitäten aufweist.

Resumen
El trazado de mapas para calcular los niveles de hueso disponi- References
bles para colocación de implantes en maxilar anterior evita al- Avivi-Arber, L. & Zarb, G. (1996) Clinical effectiveness of im-
gunos de los problemas asociados con el TAC. La intención de plant-supported single-tooth replacement: the Toronto

37
Allen & Smith
study. International Journal of Oral and Maxillofacial Im-
plants 11: 311–321.
Henry, P., Laney, W., Jemt, T., Harris, D., Krogh, P.H.J., Polizzi,
G., Zarb, G.A. & Herrman, I. (1996) Osseointegrated im-
plants for single tooth replacement: a prospective 5-year
multicenter study. International Journal of Oral and Maxillo-
facial Implants 11: 450–455.
Eckerdal, O. & Kvint, S. (1986) Presurgical planning for osseo-
integrated implants in the maxilla. International Journal of
Oral and Maxillofacial Surgery 15: 722–726.
Schwarz, M., Rothman, S.L., Chafetz, N. & Rhodes, M. (1989)
Computed tomography in dental implant surgery. Dental
Clinics of North America 33: 557–597.
38
Lam, E., Ruprecht, A. & Yang, J. (1995) Comparison of two-
dimensional orthoradially reformatted computed tomo-
graphy and panoramic radiography for dental implant treat-
ment planning. Journal of Prosthetic Dentistry 74: 42–46.
Wilson, D.J. (1989) Ridge mapping for determination of al-
veolar ridge width. International Journal of Oral and Max-
illofacial Implants 4: 41–43.
Traxler, M., Ulm, C., Solar, P. & Lill, W. (1992) Sonographic
measurement versus mapping for determination of residual
ridge width. Journal of Prosthetic Dentistry 67: 358–361.